Form & Letter Request

If your child is a current patient at Parker Place, and needs a form completed or a letter generated by our office, please use the form below to submit your request.

We ask that you please keep in mind the following guidelines:

There is an administrative fee of $25 per request. A payment link will be sent to you via email and/or text, and once payment has been received, our team will begin working on your forms.
We require a minimum of three (3) business days’ notice to fulfill requests for forms or letters. Additional advance notice is appreciated!
For requests involving school or work absence or similar accommodations, the provider’s decision to accept or deny the request will be based on medical necessity; factors to be considered include your child’s medical history, prognosis, and compliance with appointments and overall treatment plan.
The provider and/or a member of our staff may reach out to you for clarification or if additional information is needed.

Your Name

First Name

Last Name

Patient's Name

First Name

Last Name

Patient's DOB

YYYY

Phone

(###)

###

####

Provider at Parker Place

Type of Request

If your child needs the provider to complete a medical form, please email the form PDF or link to info@parkerplaceannapolis.com after you submit this request!

Reason for the Request

Please be as detailed as possible regarding why your child needs the form or letter!

Additional Information

If you are requesting a letter, please indicate the following: recipient (for example: name of school, name of employer, etc.) and any other specific information that should be included!

Date Needed

YYYY

Permission to Release Health Information

By typing my initials, I am giving Parker Place permission to disclose my child's private health information to the recipient of the requested form and/or letter. This request is considered to be an addendum to my child's Authorization for Release of Records at Parker Place.

Acknowledgment of Fee

By typing my initials, I confirm that I am aware of the $25 fee associated with this request, and that I will utilize the link sent to me to submit payment prior to my request being completed.